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1 - 20 of 54

Mills M. The Guardian. September 3, 2022

Families experiencing medical error can harbor frustration with the system but also with themselves for allowing care mistakes to take their loved one. This first-person account shares the story of a mother’s loss of a daughter to sepsis. The memoir illustrates how lack of respect for a family’s concern contributed to the incident.

Parry C. The Pharmaceutical JournalApril 22 2021.

Weight-based prescribing in children harbors challenges to accurate medication dosing. This story discusses an examination of factors contributing to ten-fold medication errors in pediatric care. The author summarizes an ongoing investigation which has identified polypharmacy and information system weaknesses as being among the contributors to the problem.

Morris S, O’Hara J. Pharmacuetical Journal. February 26, 2021.

It is a challenge to track medical errors that take place in the home environment, yet it is understood they happen and can cause harm. This article discusses errors that parents make in providing medications to their children. The authors advocate for engaging parents as partners to improve care safety in the home.

Phipps D, Ashour A, Riste L, et al. The Pharmaceutical Journal. 2020;305(7943, 7944). November 10, December 1, 2020.

Dispensing mistakes are a common contributor to preventable adverse events in community pharmacies. Part 1 of this two-part series discusses factors that contribute to dispensing errors and summarizes methods for managing risks stemming from missteps. Part 2 focuses on preventing situations that enable errors and the role pharmacists have in minimizing dispensing errors in daily practice.

Ralston W. Wired Magazine. November 11, 2020.

Health information system downtime can affect patient safety. This story discusses a ransomware incident that affected patient care and the potential ramifications of a legal examination of accountability for the information system failure that contributed to a patient death.
Stevis-Gridneff M, Apuzzo M, Pronczuk M. New York Times. 2020;August 8.
Residential care facilities have been challenged by COVID-19. This story examines the weakness of care processes in nursing homes in Europe that have been revealed due to the pandemic. Data gaps, resource allocation choices, and hospital space considerations are noted situations that have resulted in unintended consequences, reducing the safety of care for this at-risk population. 
Honderich H, Popat S. BBC News, Washington. 2020;Jul 27.
Omissions in standard procedure contribute to harm in a wide range of care environments. This news story highlights system failures associated with inmate testing prior to a transfer that resulted in a prison coronavirus outbreak. The story highlights how conditions, activities and design of the facility are contributing to the outbreak. 
Guirguis A. The Pharmaceutical Journal. 2020;304.
Users of illicit substances are vulnerable to a variety of health concerns. This article discusses how the COVID-19 pandemic places illicit drug users at increased risk for COVID-19 due to their predisposition to infection and social contact; how disruptions to illicit drug supply chains increase risk for overdose due to drug substitution and; the impact of missing out on drug treatment services. The piece highlights the role of pharmacists in keeping this marginalized patient population safe.

Calvert J, Arbuthnott G. The Sunday Times (UK). March 1, 2020.

Front line staff concerns which are not treated with respect can undermine improvement efforts and patient safety. This news story illustrates how safety culture can be derailed by leadership misalignment of patient care mission with attainment of favorable pubic-facing quality ratings.
Lintern S. The Independent. January 15, 2020.
The Francis report is a primary example of a large-scale examinations of health care system failure. This story highlights that transparency, duty of candor and whistleblowing protections have improved since the report’s release a decade ago but that more work needs to be done to fully embed a culture of safety throughout the United Kingdom National Health Service.
Human factors expertise in targeted personnel is a noted health care system improvement strategy. This news piece highlights the National Health Service (NHS) effort to require organizations to develop and employ patient safety specialists with distinct human factors and safety science skill sets to embed system improvements in their organizations and throughout the NHS.
Lintern S. The Independent. November 18, 2019.
Infants are particularly vulnerable to patient safety errors. This article shares preliminary findings of a government investigation into infant deaths at a National Health Service Trust hospital. Initial insights discussed include the lack of a safety culture at the Trust Hospital facilitating the persistence of the problems.
Whitaker P. New Statesman. August 2, 2019;148:38-43.
Artificial intelligence (AI) and advanced computing technologies can enhance clinical decision-making. Exploring the strengths and weaknesses of artificial intelligence, this news article cautions against the wide deployment of AI until robust evaluation and implementation strategies are in place to enhance system reliability. A recent PSNet perspective discussed emerging safety issues in the use of artificial intelligence.
O'Loughlin E.
Large-scale adverse events should lead to system examination and improvement. This newspaper article reports on misread cervical cancer tests that resulted in 208 women receiving false negative results over a 4-year period from a publicly funded smear test program in Ireland and the government inquiry launched in response to this large-scale failure.
Vosper H; Lim R; Knight C; et al; CIEHF Pharmaceutical Human Factors Special Interest Group. Clinical Pharmacist. 2018;10(2).
Traditionally, efforts to reduce medical errors have focused on modifying individual behavior rather than systems. This article reviews the use of systems thinking models to address failure and discusses how small problems can combine into organizational failure. The authors suggest that the health care workforce develop human factors engineering competencies to achieve improvements.
Donnelly L.
Delays in care and diagnosis can result in patient harm. This news article reports on the trend of delays in prehospital emergency care as a safety concern in the United Kingdom and describes an incident involving an infant who died from sepsis after a call handler from the NHS 111 service failed to recognize that the child required urgent care.
Anthes E. Nature. 2015;523:516-8.
Checklists have been advocated as a safety strategy, despite challenges that hinder their success. Reporting on the unmet potential of checklists to reliably improve health care safety, this news article describes how resistance to checklist use, design problems, and implementation factors can limit their effectiveness.